Better symptom management may prevent most emergency department visits for patients with cancer

Laura Panattoni

More than half of ED visits among patients with cancer could be prevented through better symptom management and greater use of tailored outpatient care, according to study results.

“My hope is that seeing these data will promote innovative thinking and investment in how oncology teams manage patient symptoms,” Laura Panattoni, PhD, staff scientist at Fred Hutchinson Cancer Research Center’s Hutchinson Institute for Cancer Outcomes Research, said in a press release. “Managing nausea, pain, dehydration, diarrhea and other symptoms in an outpatient setting has great potential to improve patient experience and decrease the cost of care.”

Panattoni and colleagues analyzed data from 1,581 patients with solid tumor cancers who underwent chemotherapy, radiation or both. All patients underwent treatment in a 13-county region in Washington state.

The researchers used a list of symptoms that federal health authorities identified as preventable, in combination with symptoms targeted by patient-reported outcome tools.

Of the 2,400 ED visits recorded by these patients, 53% resulted from symptoms that potentially could be managed in outpatient settings, researchers concluded.

HemOnc Today spoke with Panattoni about the study results, and the importance of developing methods to accurately identify potentially preventable ED visits.

Question: What prompted this study?

Answer: Unnecessary ED visits have a detrimental impact on patients with cancer and their families, contributing to avoidable hospitalizations, increased out-of-pocket expenses and a poor patient experience. From a health system perspective, preventing such visits is critical to improving patient outcomes and decreasing health care spending. In response to Hutchinson Institute for Cancer Outcomes Research’s initial quality reports on regional hospital use during treatment, we established a community working group comprised of delivery organizations, payers and patient advocates focused on identifying interventions to reduce ED visits and hospital use. The working group wanted to understand why patients ended up in the ED or hospital, and how much of a reduction we could expect. Therefore, I led a study to identify potentially preventable ED visits among commercially insured patients in western Washington, and their associated costs. Potentially preventable ED visits involve symptoms that could have been managed in the outpatient setting, such as nausea or pain. This question is timely, as CMS proposed a new quality metric — the Admissions and Emergency Department Visit for Patients Receiving Outpatient Chemotherapy Measure — for potentially preventable ED visits during treatment. This metric targets 10 symptoms: anemia, dehydration, diarrhea, vomiting, fever, nausea, neutropenia, pain, pneumonia and sepsis). It is under review, but there is a proposed effective date of 2020. In our analysis, we looked at the CMS measurement, the symptoms included in the patient-reported outcomes tools, and potentially preventable chronic conditions identified by the Agency for Healthcare Research and Quality’s Prevention Quality Indicators.

Q: What did you find?

A: When we analyzed the diagnoses associated with the new CMS metric, we found that 41% of ED visits would have been categorized as potentially preventable due to cancer-related symptoms. After adding the symptoms targeted by patient-reported outcomes tools and chronic conditions, we found that the percentage of potentially preventable ED visits increased to 53%. We also analyzed the effect of examining all diagnosis code fields associated with an ED visit rather than looking at the first relevant field, which is the standard approach for quality reporting. This analysis showed that up to 73% of ED visits included a ‘potentially preventable’ diagnosis code, with 20% including both a potentially preventable cancer-related and chronic disease-related code. Next, we reported the most common potentially preventable diagnoses, based on the first relevant diagnosis code field. We found that 27% of ED visits had a pain diagnosis as the primary reason for the visit, followed by fever and dyspnea, which each accounted for 6% of ED visits.

Q: What is the take-home message for clinicians?

A: Our study suggests more than half of the ED visits potentially resulted from inadequately controlled cancer symptoms. To reduce ED visits, providers should focus first on managing cancer symptoms targeted by both the CMS metric and emerging patient-reported outcomes tools, and focus secondly on how chronic care management is integrated into oncology care.

Q: Do you plan to conduct additional research in this area?

A: Yes. The new CMS metric also targets potentially preventable inpatient admissions. Analyzing these ED and hospitalization outcomes jointly may inform stakeholders in the oncology, payer and policy communities about how to improve ED and inpatient measure for oncology, identify interventions that reduce their incidence, and define future research on reducing this avoidable utilization. We also plan to report the out-of-pocket costs patients face as one measure of their burden.

Q: Is there anything else that you would like to mention?

A: There are two ‘bigger picture’ issues here. The results from this study should be viewed in the context of a wider policy movement in oncology to improve quality and reduce avoidable utilization through delivery reform, performance measurement and new alternative payment models, such as the Oncology Care Model. These models all include risk-adjusted ED utilization and hospitalization as performance metrics. Targeting these outcomes is a great way for practices to meet the challenge of these new payment models. Secondly, this study suggests that the best practice for incorporating the new CMS metric into quality improvement initiatives is to understand its limitations and opportunities. The CMS metric excludes cancer symptoms targeted by newer interventions, such as patient-reported outcome tools and avoidable ED visits identified by other performance metrics. This suggests that practice managers should combine the CMS metric with other metrics and the wider literature on reducing ED visits to yield the greatest improvements in care. – by Jennifer Southall

Reference:

Panattoni L, et al. Abstract 6505. Presented at: ASCO Annual Meeting; June 2-6, 2017; Chicago.

For more information:

Laura Panattoni, PhD, can be reached at Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. North, P.O. Box 19024, Seattle, WA 98109; email: lpanatto@fredhutch.org.

Disclosure: Panattoni reports no relevant financial disclosures.

Laura Panattoni

More than half of ED visits among patients with cancer could be prevented through better symptom management and greater use of tailored outpatient care, according to study results.

“My hope is that seeing these data will promote innovative thinking and investment in how oncology teams manage patient symptoms,” Laura Panattoni, PhD, staff scientist at Fred Hutchinson Cancer Research Center’s Hutchinson Institute for Cancer Outcomes Research, said in a press release. “Managing nausea, pain, dehydration, diarrhea and other symptoms in an outpatient setting has great potential to improve patient experience and decrease the cost of care.”

Panattoni and colleagues analyzed data from 1,581 patients with solid tumor cancers who underwent chemotherapy, radiation or both. All patients underwent treatment in a 13-county region in Washington state.

The researchers used a list of symptoms that federal health authorities identified as preventable, in combination with symptoms targeted by patient-reported outcome tools.

Of the 2,400 ED visits recorded by these patients, 53% resulted from symptoms that potentially could be managed in outpatient settings, researchers concluded.

HemOnc Today spoke with Panattoni about the study results, and the importance of developing methods to accurately identify potentially preventable ED visits.

Question: What prompted this study?

Answer: Unnecessary ED visits have a detrimental impact on patients with cancer and their families, contributing to avoidable hospitalizations, increased out-of-pocket expenses and a poor patient experience. From a health system perspective, preventing such visits is critical to improving patient outcomes and decreasing health care spending. In response to Hutchinson Institute for Cancer Outcomes Research’s initial quality reports on regional hospital use during treatment, we established a community working group comprised of delivery organizations, payers and patient advocates focused on identifying interventions to reduce ED visits and hospital use. The working group wanted to understand why patients ended up in the ED or hospital, and how much of a reduction we could expect. Therefore, I led a study to identify potentially preventable ED visits among commercially insured patients in western Washington, and their associated costs. Potentially preventable ED visits involve symptoms that could have been managed in the outpatient setting, such as nausea or pain. This question is timely, as CMS proposed a new quality metric — the Admissions and Emergency Department Visit for Patients Receiving Outpatient Chemotherapy Measure — for potentially preventable ED visits during treatment. This metric targets 10 symptoms: anemia, dehydration, diarrhea, vomiting, fever, nausea, neutropenia, pain, pneumonia and sepsis). It is under review, but there is a proposed effective date of 2020. In our analysis, we looked at the CMS measurement, the symptoms included in the patient-reported outcomes tools, and potentially preventable chronic conditions identified by the Agency for Healthcare Research and Quality’s Prevention Quality Indicators.

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Q: What did you find?

A: When we analyzed the diagnoses associated with the new CMS metric, we found that 41% of ED visits would have been categorized as potentially preventable due to cancer-related symptoms. After adding the symptoms targeted by patient-reported outcomes tools and chronic conditions, we found that the percentage of potentially preventable ED visits increased to 53%. We also analyzed the effect of examining all diagnosis code fields associated with an ED visit rather than looking at the first relevant field, which is the standard approach for quality reporting. This analysis showed that up to 73% of ED visits included a ‘potentially preventable’ diagnosis code, with 20% including both a potentially preventable cancer-related and chronic disease-related code. Next, we reported the most common potentially preventable diagnoses, based on the first relevant diagnosis code field. We found that 27% of ED visits had a pain diagnosis as the primary reason for the visit, followed by fever and dyspnea, which each accounted for 6% of ED visits.

Q: What is the take-home message for clinicians?

A: Our study suggests more than half of the ED visits potentially resulted from inadequately controlled cancer symptoms. To reduce ED visits, providers should focus first on managing cancer symptoms targeted by both the CMS metric and emerging patient-reported outcomes tools, and focus secondly on how chronic care management is integrated into oncology care.

Q: Do you plan to conduct additional research in this area?

A: Yes. The new CMS metric also targets potentially preventable inpatient admissions. Analyzing these ED and hospitalization outcomes jointly may inform stakeholders in the oncology, payer and policy communities about how to improve ED and inpatient measure for oncology, identify interventions that reduce their incidence, and define future research on reducing this avoidable utilization. We also plan to report the out-of-pocket costs patients face as one measure of their burden.

Q: Is there anything else that you would like to mention?

A: There are two ‘bigger picture’ issues here. The results from this study should be viewed in the context of a wider policy movement in oncology to improve quality and reduce avoidable utilization through delivery reform, performance measurement and new alternative payment models, such as the Oncology Care Model. These models all include risk-adjusted ED utilization and hospitalization as performance metrics. Targeting these outcomes is a great way for practices to meet the challenge of these new payment models. Secondly, this study suggests that the best practice for incorporating the new CMS metric into quality improvement initiatives is to understand its limitations and opportunities. The CMS metric excludes cancer symptoms targeted by newer interventions, such as patient-reported outcome tools and avoidable ED visits identified by other performance metrics. This suggests that practice managers should combine the CMS metric with other metrics and the wider literature on reducing ED visits to yield the greatest improvements in care. – by Jennifer Southall

Reference:

Panattoni L, et al. Abstract 6505. Presented at: ASCO Annual Meeting; June 2-6, 2017; Chicago.

For more information:

Laura Panattoni, PhD, can be reached at Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. North, P.O. Box 19024, Seattle, WA 98109; email: lpanatto@fredhutch.org.

Disclosure: Panattoni reports no relevant financial disclosures.